1. Mental Health Nursing II NURS 2310
Unit 3
Therapeutic Communication

2. Defining therapeutic milieu
Objective 1
Defining therapeutic milieu

3. The therapeutic milieu is a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual.
Within this structured environment, the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life.

4. Objective 2
Analyzing the nurse’s role in maintaining the therapeutic milieu in an inpatient psychiatric/mental health setting

5. The nurse maintains the therapeutic milieu in
the inpatient setting by:
Encouraging health promotion
Providing therapeutic interaction
Allowing clients to participate in governing the unit
Expecting the client to take responsibility for his or her own behavior
Utilizing peer pressure or peer support as a tool to bring about acceptable group norms
Dealing with inappropriate behaviors as they occur
Avoiding restrictions and punishments

6. Objective 3
Reviewing the components
of nurse-client relationship development and therapeutic communication

7. Therapeutic use of self:
Ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions
Therapeutic communication:
Consists of verbal and nonverbal techniques that focus on the client’s needs and advance the promotion of healing and change
Encourages the exploration of feelings and fosters understanding of behavioral motivation
Promotes trust, discourages defensiveness, and is nonjudgmental

8. Active listening: Feedback:
Being attentive to what the client is saying both verbally and nonverbally
Facilitative skills include –
facing the client squarely
observing an open posture
leaning toward the client
establishing eye contact
maintaining a relaxed demeanor
Feedback:
Communication method that helps the client consider a modification of behavior

9. Therapeutic relationship:
Interaction between two people in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention
Goal-oriented
goal of the relationship determined jointly by nurse and client
goal is most often directed at learning and growth promotion in an effort to bring about some type of change in the client’s life
may be based on a problem-solving model

10. Conditions essential to the development of a
therapeutic relationship include:
Rapport
special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude
establishing rapport may be accomplished by discussing non-health-related topics
Genuineness
the ability to be open, honest, and “real” in interactions

11. Developing therapeutic relationships (cont’d)
Trust
confidence in another person’s presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested
providing a blanket when the client is cold
providing food when the client is hungry
keeping promises
being consistent
ensuring confidentiality

12. Developing therapeutic relationships (cont’d)
Respect
unconditional positive regard
calling the client by name
spending time with the client
allowing sufficient time to answer the client’s questions or concerns
always being open and honest
striving to understand the motivation behind the client’s behavior
Empathy
process in which one is able to see beyond outward behavior and accurately sense another’s inner experience

13. Objective 4
Exploring the phases of the therapeutic relationship

14. Phases of the therapeutic relationship:
Preinteraction phase
Preparation for the first encounter with the client
Orientation (Introductory) phase
The nurse and client become acquainted
Working phase
Accomplishment of the therapeutic work of the relationship
Termination phase
Bringing a therapeutic conclusion to the relationship

15. Boundary issues within a professional relationship may include:
Transference
When the client unconsciously attributes to the nurse feelings and behavioral dispositions formed toward a person from his or her past
Countertransference
The nurse’s behavioral and emotional response to the client which may be related to unresolved feelings toward significant others from the nurse’s past, or may be generated in response to transference feelings on the part of the client

16. Boundary issues (cont’d)
Self-disclosure
May be appropriate when the information to be shared is judged to be therapeutically beneficial to the client
Never used for the purpose of meeting the nurse’s own needs
Gift-giving
Professional judgment
Institutional policy
Never financial
suggest a donation elsewhere

17. Boundary issues (cont’d)
Touch
Caring touch with no associated physical need can be therapeutically appropriate
Beware of situations in which touch may be misinterpreted, culturally unacceptable, or dangerous
paranoid patient
psychotic client

18. Warning signs that may indicate a potential breech in professional boundaries in the nurse-client relationship include:
Favoring one client’s care over another’s
Swapping assignments with another nurse to care for a particular client
Giving special attention or treatment to one client over others
Spending free time with one particular client
Sharing personal information or work concerns with a client
Continuing contact/communication with a client after discharge

19. Objective 5
Correlating appropriate modes of therapeutic communication with specific psychiatric behaviors

20. Modes of therapeutic communication:
Using silence
gives the client the opportunity to collect and organize thoughts
Accepting
conveys an attitude of reception and regard
Giving recognition
acknowledging
Offering general leads
offers the client encouragement to continue
Making observations
verbalizing what is observed or perceived
Restating
repeating the main idea of what the client has said
Encouraging description of perceptions
asking the client to verbalize what is being perceived

21. Therapeutic communication (cont’d)
Reflecting
referring questions and feelings back to the client so that they may be recognized and accepted
Focusing
taking notice of a single idea or a single word
works well with the client who is moving rapidly from one thought to another
not to be used with a client who is anxious
Presenting reality
when a client has a misperception of the environment, the nurse defines reality
Voicing doubt
expressing uncertainty as to the reality of percpetions

22. Objective 6
Exploring the
concept of
therapeutic
community

23. The therapeutic community holds that everything that happens to the client or within the client’s environment is considered to be part of the treatment program.
Community factors, such as social interactions, the physical structure of the treatment setting, and schedule of activities may generate negative responses which are used as examples to help the client learn how to manage stress more adaptively in real-life situations.

24. Conditions that promote the therapeutic
community include:
The fulfillment of basic physiological needs
The conduciveness of the physical facilities to achievement of the goals of therapy
The existence of a democratic form of self-governance
The assignment of responsibilities based on each client’s capabilities
The scheduling of a structured program of social and work-related activities
The inclusion of community and family with regards to discharge planning

25. Examining the use of groups as a therapeutic tool
Objective 7
Examining the use of groups as a therapeutic tool

26. Membership is generally
Group:
Collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose
Membership is generally
by chance (born into the group)
by choice (voluntary affiliation)
by circumstance (the result of life-cycle events over which an individual may or may not have control)
Group Therapy = a form of psychosocial treatment in which a number of clients meet together with a therapist for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies.

27. Use of a group as a therapeutic tool:
Instillation of hope
Universality
Imparting of information
Altruism
Corrective recapitulation of the primary family group
Development of socializing techniques
Imitative behavior
Interpersonal learning
Group cohesiveness
Catharsis
Existential factors

28. Identifying group types, roles, functions, development and stages
Objective 8
Identifying group types, roles, functions, development and stages

29. Functions of a group: Socialization Support Task completion
Camaraderie
Informational
Normative
enforcement of established norms
Empowerment
Governance
rules committees

30. Types of groups: Task Groups Teaching Groups
accomplishing a specific outcome or task
focus on problem-solving and decision-making
Teaching Groups
exist to convey knowledge and information to a number of individuals
Supportive/Therapeutic Groups
concerned with preventing future upsets by teaching effective ways of dealing with emotional distress
Self-Help Groups
allow clients to talk about their fears and relieve feelings of isolation while receiving comfort and advise from others undergoing similar experiences

31. Member roles within groups:
Task Roles
Coordinator
Evaluator
Elaborator
Energizer
Initiator
Orienter
Individual Roles
Aggressor
Blocker
Dominator
Mute/Silent member
Maintenance Roles
Compromiser
Encourager
Follower
Gatekeeper
Harmonizer
Monopolizer
Recognition Seeker
Seducer

32. Initial or Orientation Phase
Phases of group development:
Phase I
Initial or Orientation Phase
Group activities – leader and members work together to establish the rules that will govern the group
Leader expectations – leader expected to orient members to specific group processes, encourage members to participate without disclosing too much too soon, promote an environment of trust, and ensure group rules don’t interfere with goal fulfillment
Member behaviors – members have not yet established trust; fear of not being accepted by the group

33. Phases of group development (cont’d)
Phase II
Middle or Working Phase
Group activities – productive work toward completion of the task is undertaken; problem-solving and decision-making occur
Leader expectations – role diminishes and becomes one of facilitator
Member behaviors – trust established among members; members turn to each other more often, and less so to the leader; members accept criticism from others and use it constructively to create change

34. Phases of group development (cont’d)
Phase III
Final or Termination Phase
Group activities – termination process discussed in depth for several meetings before the final session
Leader expectations – the leader encourages group members to reminisce about what has occurred, review the goals, and discuss actual outcomes
Member behaviors – grief response may be evident; may lead to discussion of previous losses; successful termination of the group may help members develop the skills needed when losses occur in other dimensions of their lives.